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B2 Gynaecology > Menopause > Flashcards

Menopause Flashcards

1
Q

What is the definition of menopause?

A

Final menstrual period

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2
Q

What is the average age of menopause?

A

51

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3
Q

When is a woman postmenopausal?

A

12 months after her final menstrual period

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4
Q

What is premature menopause, or premature ovarian insufficiency?

A

Menopause before the age of 40

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5
Q

What is early menopause?

A

Menopause before the age of 45

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6
Q

When do smokers go through menopause, compared to non-smokers?C

A

May go through menopause 1 year earlier

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7
Q

How is menopause diagnosed?

A

Clinically
Based on cessation of menstruation for a period of 12 months

If required, can be confirmed by
- elevated gonadotrophins (FSH) and low oestradiol

A low AMH is NOT a diagnostic test

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8
Q

What is the physiology of menopause?

A

Fall in the number of oocytes
Fall in the ability of the ovary to produce oestrogens (especially oestradiol) and progestogens
Leads to an increase in the level and pulsatile release of FSH from the pituitary, in an effort to stimulate the ovary to produce oestrogens

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9
Q

What are the vasomotor symptoms of menopause, and what causes them?

A

Hot flushes
Night sweats

Increase in the pulsatile release of FSH

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10
Q

What’s are the genital symptoms of menopause, and what causes them?

A

Dyspareunia
Vulval itching
Prolapse

Vaginal atrophy and dryness

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11
Q

What are the urinary symptoms of menopause?

A

Urinary frequency
Dysuria
Recurrent UTIs
Urinary incontinence (occasionally)

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12
Q

What are the psychological symptoms of menopause?

A 
Fatigue
Depression
Mood instability
Decreased libido
Insomnia
Short term memory loss

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13
Q

Which women should have the bone density measured, and how should it be measured?

A

Those at increased risk of fracture

Using DXA

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14
Q

What lifestyle changes are recommended to manage menopausal symptoms?

A 
Stress reduction
Regular exercise
Optimal weight management
Appropriate diet
Avoidance of smoking, excessive alcohol and caffeine intake
Mindfulness training and CBT

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15
Q

What are contraindications to HRT?

A 
Pre-existing cardiovascular and cerebral vascular disease
Previous hx VTE
Previous breast cancer
Starting HRT >60 years old
Undiagnosed vaginal bleeding

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16
Q

In what circumstances should HRT be used with caution?

Relative contraindications

A

A history of endometrial cancer
Active SLE
High cardiovascular risk
Abnormal liver function

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17
Q

For women with a uterus, HRT should contain ______ for at least ____ days per month to provide endometrial protection

A

Progestogens

14

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18
Q

What is the main advantage of HRT, apart from addressing menopausal symptoms?

A

Increases bone density

Reduces fracture risk

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19
Q

What is the effect of HRT on the breast?

A

Combined E + P increases the risk of breast cancer

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20
Q

What is the effect of oral HRT on VTE risk?

A

Doubles the risk

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21
Q

What is the effect of transdermal HRT cf oral HRT re: VTE risk?

A

Transdermal HRT may have a more favourable effect on VTE risk and may be a safer option in those at increased risk of VTE

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22
Q

Cessation of HRT may lead to a recurrence of vasomotor symptoms in around what % of women?

A

50%

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23
Q

What is the most effective therapy for vaginal symptoms of menopause?

A

Local vaginal oestrogen

Non-hormonal vaginal moisturisers may also be useful for dryness

  • Replens
  • acidic gels
  • silicone based lubricants
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24
Q

Women with premature or early menopause should be offered HRT at least until age…

A

50-51

Unless otherwise contraindicated

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25
Q

What are the non-hormonal medical options to manage menopause, that are evidence-based as being superior to placebo?

A 
Gabapentin
Venlafaxine
Desvenlafaxine
Citalopram
Escitalopram
Paroxetine
Fluoxetine
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26
Q

Paroxetine and Fluoxetine should not be taken in women taking _______ as they may interfere with _____’s metabolism

A

Tamoxifen

27
Q

What is Tibolone?

A

Synthetic steroid with oestrogenic, prostogenic and weak androgenic effects

28
Q

Tibolone should only be used in women ________________

As it may cause irregular bleeding in younger women

A

> 12 months since menopause

29
Q

Which local vaginal oestrogen therapy has less systemic absorption, and is therefore preferable in women with a history of breast cancer?

A

Oestriol preparations (Ovestin) better than Oestradiol

30
Q

Can HRT be used in survivors of breast cancer?

A

Current data do NOT support its use
Tibolone is also not recommended
Testosterone is also not recommended

31
Q

For women with a previous history of breast cancer on HRT, what follow up is recommended?

A

Annual review including Mammography

32
Q

What was the conclusion of the LIFT Trial?

A

Tibolone reduced the risk of fracture and breast cancer and possibly colon cancer but increased the risk of STROKE in older women with osteoporosis
- and the increased risk of stroke meant that the trial was terminated early.

*Increased risk of breast cancer in women with previous history of breast cancer

33
Q

What was the conclusion of the HERS Study?

Heart and Estrogen / progestin replacement study

A

No overall effect on CHD
Apparent increased risk in the first year after randomisation

Recruited women with documented CHD prior to randomisation

34
Q

What is the prevalence of SEVERE vasomotor symptoms in menopausal women?

A

1:4

35
Q

What is the prevalence of SEVERE psychological symptoms in menopausal women?

A

1:3

36
Q

What did the Global Consensus Statement on MHT say?

A

MHT is the most effective treatment for vasomotor symptoms associated with menopause at any age.
Benefits are more likely to outweigh risks for symptomatic women before the age of 60, or within 10 years after menopause

37
Q

What is the effect of MHT on dementia, as per IMS?

A

Decreases dementia if MHT commenced during midlife
Increases dementia if MHT commenced after midlife

(Critical window theory)

38
Q

What effect does MHT have on urinary incontinence?

A

Increases it

IMS

39
Q

What is the effect of MHT on cervical cancer?

A

No effect

IMS

40
Q

What is the absolute risk of stroke with Tibolone, compared to placebo?

A

Tibolone: 2.8/1000 woman years
Placebo: 1/1000 woman years

41
Q

What are Raloxifene and Bazedoxifene, and what is their role in managing the menopause?

A

SERMs
Alleviate VMS, urogenital atrophy, preserves bone and does not stimulate the endometrium
Effect on VTE needs clarification

42
Q

What is the effect of Clonidine on hot flushes, when compared to placebo?

A

Slightly more effective in a meta-analyasis

43
Q

What are the disadvantages of oral oestrogen (compared to transdermal)

A 
Increased risk of 
- VTE
- Cholelithiasis
Increased
- SHBG (therefore decreased testosterone)
- Thyroid binding globulin
Administration of higher total dose
44
Q

What is the safest form of progesterone with regards to

  • breast cancer risk
  • cardiovascular risk
A

Micronised progesterone (brand name Utrogestan)

Or LNG-IUS

45
Q

In the EARLY menopause transition, there is a persistent difference of ____ days or more in the length of consecutive cycles

A

7

46
Q

In the LATE menopause transition, there are periods of amenorrhoea of ___ days or more, as well as two other symptoms

A

60

Frequent an ovulation
The onset of perimenopausal symptoms

47
Q

What other parts of overall health can be checked when a woman presents with menopause?

A

Midlife assessment

Cervical smear
Mammogram
Lipids
FBC / Ferritin
TSH, renal and liver function, FOBT
Vit D in at risk women
48
Q

By what % does testosterone levels drop in menopause?

A

50%

49
Q

What is the main source of oestrogen in a postmenopausal woman?

A

Estrone (E1) aromatised in adipose tissue from androstenedione produced by ovarian stroma and adrenal glands

50
Q

What is the median duration of vasomotor symptoms for women?

What % will have vasomotor symptoms continue for up to 14 years?

A

Median duration: 7 years.

40% have sx that continue for up to 14 years.

51
Q

What is the pathophysiology for urological symptoms of menopause?

A
  • Recurrent UTIs: raised vaginal pH >4.5 enhances enterobacterial growth.
  • SUI and UUI: atrophic urethritis with diminished urethral seal, loss of compliance and irritation.
52
Q

Describe the indications for FSH level to diagnose menopause and how you would perform this investigation.

A

FSH >30, two levels taken 6 weeks apart:
<40 years old when menopause suspected.
40-45 years old with menopausal sx and change in menstrual cycle.

Single FSH >30:
Amenorrhoeic and >50 years old

Do not use if on hormonal contraception.

53
Q

Recommended HRT regimen for PERImenopausal women with an intact uterus

A

Low dose (20 mcg) COCP OR
Mirena + oral or transdermal oestrogen
Still needs contraception.

54
Q

What are the indications for transdermal mode of delivery for oestrogen replacement therapy?

A
  • Less nausea (side-effect)
  • Increased risk of VTEL dose needs to be <=50 micrograms
  • Abnormal LFTs / risk of cholecystitis
  • Cardiovascular disease
  • History of migraine
55
Q

Outline the follow-up needed for a woman you have started on HRT

A
  • Review in 3-6 months: general health and breast exam.
  • Investigate any unscheduled bleeding persisting after first 6 months.
  • Annual rescreening of VTE and cardiovascular risk
  • Mammogram every 2 years
  • Consider cessation of HRT after 4-5 years.
56
Q

What are the long-term implications of menopause?

A
  • Loss of collagen affecting bones, skin, nails, vagina and pelvic ligaments.
  • Reduced neurotransmitter synthesis affecting cognition (ACh), low mood irritability and insomnia (dopamine), panick attacks and palpitations (adrenergic and noradrenergic)
  • Loss of bone density/increased fracture risk
  • Impaired endothelium function leading to HTN and atherosclerosis
  • Increased total cholesterol and LDL
  • Increased central abdominal fat deposition
  • Insulin resistance and risk of T2DM
  • Urogenital: atrophic vaginitis, urinary frequency, cystitis, incontinence, dysuria
57
Q

If a menopausal woman’s main issue is sexual dysfunction and psychosocial causes have been excluded, what treatment would you prescribe?

A

Tibolone or testosterone therapy

58
Q

What are risk factors for osteoporosis?

A
  • Women age >65
  • Low BMI
  • High alcohol intake
  • Smoking
  • FamHx osteoporosis
  • Glucocorticoid use, Cushing’s disease
  • Early menopause or hypogonadism
  • History of falls
  • Chronic inflammatory disease
  • History of eating disorder
59
Q

What life style modifications can be made to reduce the risk of osteoporosis?

A
  • Smoking cessation
  • Reducing alcohol intake
  • Weight bearing exercises
  • Maintaining normal BMI
  • Adequate sun exposure
  • Vitamin D supplement
  • Balanced diet
  • Falls risk assessment and prevention
60
Q

Outline the options available for medical osteoporosis treatment

A

Bisphosphonates:

  • Oral: alendronate, risendronate.
  • IV: zolendronate

Oestrogen therapy

61
Q

What are the side-effects of oestrogen HRT?

A
  • Vaginal bleeding
  • Fluid retention
  • Breast tenderness
  • Headaches
  • Nausea
62
Q

What are proven clinical benefits of HRT?

A
  • Reduction in vasomotor symptoms
  • Reduces risk of endometrial cancer if combined HRT
  • Prevention of osteoporosis
  • Increased bone density
63
Q

Scenario: 60 year old who went through menopause age 52 has been on combined HRT for the last 5 years. Nil significant history previously.

Discuss how you may minimise some or all of the risks now associated with HRT use but still provide effective treatment if the vasomotor symptoms recur after a trial period off HT. (4 marks)

A

Recommendations relate to COMBINED HRT (intact uterus):
○ Screen and risk stratify for cardiovascular disease: medical history, BMI/waist circumference, BP, smoking status, lipid profile, glucose tolerance screening (fasting glucose, OGTT or HbA1c).
○ Breast examination and 2-yearly mammograms.

Use low dose transdermal method as associated with:
§ No increased risk of stroke.
§ Less increased risk of cholecystitis, cardiovascular disease, VTE
• Progesterone IUS/Mirena or micronised progesterone.

Non-hormonal approaches:
§ Evidence for mindfulness, CBT
§ Lifestyle changes: weight management, smoking reduction, alcohol and caffeine reduction, exercise, diet, stress reduction.
§ Consider an SSRI and SNRI, gabapentin.

B2 Gynaecology (12 decks)

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